Asssigment

1

Effectiveness of Transitional care in Reducing Hospital Readmissions within 30 days

Among Patients with Chronic Heart Failure

Antonio Estremera

FNU

Nursing Research and Evidence-Based Practice

Professor: Dr. Carmen Lazo

November 9, 2024

2

Effectiveness of Transitional care in Reducing Hospital Readmissions within 30 days

Among Patients with Chronic Heart Failure

Chronic diseases are among the leading causes of hospitalization, death, and economic

burden globally. Chronic diseases cause 73% of all deaths and 60% of the global disease burden,

respectively. One of the major problems in chronic disease management is the frequent

readmission of patients to hospitals; this is partly because transitional care is very fragmented.

More than 50% of patients with chronic diseases are readmitted to hospitals within 30 days

following discharge (Joo & Liu, 2021). Heart failure is among the major chronic diseases. It is a

prevalent condition affecting more than 6.7 million people aged 20 years and above in the United

States (CDC, 2024). Transitional care of patients with chronic conditions such as CHF is an

important element in health care, as it appraises continuity and safety as the patients undergo

different transitions from one care setting to another. Given the above figures, transitional care

interventions are crucial in reducing readmission rates to improve patient outcomes and decrease

overall healthcare system burdens. This paper discusses transitional care's role in managing CHF

patients post-discharge to minimize early hospital readmissions, drawing on prior nursing

research to emphasize its importance.

Identification of the Problem

Hospital readmission in the first 30 days after being discharged is a recurring problem in

healthcare, especially with patients diagnosed with chronic heart failure. These readmissions

may indicate potential gaps in discharge planning, patient education, and support in the post-

discharge periods, which are integral to transitional care (Ayenew et al., 2023). The majority of

patients with CHF are not engaged in illness self-management because of complex medical

regimens, diet restrictions or continuous monitoring. According to Becker et al. (2021), these

3

readmissions for admission happen due to failure in communication, follow-up services, and

support of such patients any time they go to their homes from the hospital. This issue is linked to

patient morbidity and mortality and healthcare system expenditures. Managing these factors may

improve post-discharge transitional care measures to improve patient stability and reduce

readmission rates in these populations (Rammohan et al., 2023).

Significance of the Problem to Nursing

This issue of readmission among CHF patients is highly significant in the nursing field,

especially in transitional and community-based settings. Nurses are central in discharge

planning, patient education, and coordinating care to support the patient through the transitional

period. Continuation of care is one of the major responsibilities of nursing professionals,

something quite relevant to these patients, who require detailed guidance in managing their

condition successfully at home (Karam et al., 2021). Nurses can help promote improved

compliance with treatment regimens, reduced medication errors, and increased patient-family

empowerment to engage in self-care through implementing and refining transitional care

strategies. The roles promote patient outcomes and support healthcare goals of quality of life and

preventable hospital readmissions. Transitional care, therefore, allows nurses to apply advanced

skills in the coordination of care, patient advocacy, and working collaboratively with other

professionals from other disciplines.

Purpose of the Research

This study aims to identify gaps in the current transitional care interventions and compare

the 30-day readmission rate for patients with chronic heart failure. This research will further

refine the understanding of which aspects of transitional care, including follow-up visits, patient

education, and home health monitoring, are the most valuable for avoiding early readmissions.

4

The research also aims to investigate how tailored transitional care plans can be adapted to meet

patients' individual needs, recognizing that CHF patients vary in severity, comorbid conditions,

and social support. The ultimate goal of this study is to provide evidence-based

recommendations for healthcare providers, particularly nurses, on best practices for managing

CHF patients post-discharge to improve outcomes and reduce readmissions.

Research Questions

1. What specific components of transitional care are most effective in reducing 30-day

readmission rates for patients with chronic heart failure?

2. How does patient education and self-management support during the transition period

impact readmission rates in this population?

3. How can individualized care plans enhance the effectiveness of transitional care for

patients with CHF?

4. What role do follow-up interventions, such as home visits or telehealth, play in

supporting CHF patients post-discharge?

Master's Essentials Aligned with the Topic

Essential I: Background for Practice from Sciences and Humanities

This essential underscores the need for nursing practice based on a wide knowledge of

sciences and humanities. During the care of patients with CHF, nurses will draw knowledge from

physiology, pharmacology, and patient psychology to develop comprehensive transitional care

plans addressing both physical and mental health. By integrating these multifaceted arenas of

cognition, nurses will be better equipped to develop holistic and personalized plans of care that

meet the complex needs of CHF patients during their transition from hospital to home.

Essential II: Organizational and Systems Leadership

5

This essential highlights the need for a higher level of professional nursing leadership

competencies to maneuver and coordinate healthcare systems environment solutions efficiently.

In particular, when discharging CHF patients, nurses need to involve other departments, support

the need for resources, and invest in structured transition plans to provide the appropriate care

continuity. Strong organizational and systems leadership allows nurses to reduce readmissions

through systemic improvements, demonstrating its impact on patient outcomes.

Essential III: Quality Improvement and Safety

This essential emphasizes utilizing improvement and quality management concepts to

boost the efficiency of patient safety as well as treatment. Nurses who work with CHF patients

diagnose the factors that cause readmission and implement knowledge-based changes in the

transitional care processes of the patients. Nurses play an important role in making discharge

plans safer and less risky, meaning they try to reduce the factors that can lead to readmission of

heart failure patients by paying a lot of attention to the safety of patients any time they are being

discharged or followed up.

Essential IV: Translating and Integrating Scholarship into Practice

This essential emphasizes the need for applied research conducted to enhance patient care

through the new implementation of practical nursing practices (Giddens et al., 2022).

Transitional care and readmission control are evidence-based practices. Hospital nurses use

research to handle CHF patients and apply effective solutions. They ensure the research findings

are implemented within practice, promoting patient care, especially for the most vulnerable.

Essential VII: Interprofessional Collaboration for Improving Patient and Population

Health Outcomes

6

This essential stresses the need to collaborate with an interactive and multifaceted team in

planning and providing client care that enhances pen-patient status. Transitional care for CHF

patients generally requires teamwork between nurses, physicians, pharmacists, social workers,

and home health aides to provide all health needs. This collaboration guarantees that CHF

patients get holistic and comprehensive care at each stage of their cycle, hence minimizing NICU

readmission rates.

Essential VIII: Clinical Prevention and Population Health for Improving Health

This essential calls for integrating preventive care and population health, increasing well-

being, and decreasing the number of disease incidents (Giddens et al., 2022). Transitional care

for CHF patients relates to and supports this goal by addressing the condition and averting

readmission by following up and educating patients on the necessary care. Nurses can use the

interventions to enhance the well-being of CHF patients and contribute to healthcare policies that

reduce the demands on health facilities.

7

References

Ayenew, B., Kumar, P., Hussein, A. A., Gashaw, Y., Girma, M., Ayalew, A., & Tadesse, B.

(2023). Heart failure drug classes and 30-day unplanned hospital readmission among

patients with heart failure in Ethiopia. Journal of Pharmaceutical Health Care and

Sciences, 9(1). https://doi.org/10.1186/s40780-023-00320-y

Becker, C., Zumbrunn, S., Beck, K., Vincent, A., Loretz, N., Müller, J., Amacher, S. A.,

Schaefert, R., & Hunziker, S. (2021). Interventions to Improve Communication at

Hospital Discharge and Rates of Readmission. JAMA Network Open, 4(8).

https://doi.org/10.1001/jamanetworkopen.2021.19346

CDC. (2024). Cardiovascular diseases (CVDs). Who. int. https://www.who.int/news-room/fact-

sheets/detail/cardiovascular-diseases

Giddens, J., Douglas, J. P., & Conroy, S. (2022). The Revised AACN Essentials: implications for

nursing regulation. Journal of Nursing Regulation, 12(4), 16–22.

https://doi.org/10.1016/s2155-8256(22)00009-6

Joo , J. Y., & Liu , M. F. (2021). Effectiveness of transitional care interventions for chronic

illnesses: A systematic review of reviews. Applied Nursing Research, 61, 151485.

https://doi.org/10.1016/j.apnr.2021.151485

Karam, M., Chouinard, M.-C., Poitras, M.-E., Couturier, Y., Vedel, I., Grgurevic, N., & Hudon,

C. (2021). Nursing care coordination for patients with complex needs in primary

healthcare: a scoping review. International Journal of Integrated Care, 21(1), 16.

https://doi.org/10.5334/ijic.5518

Rammohan, R., Joy, M., Magam, S. G., Natt, D., Patel, A., Akande, O., Yost, R. M., Bunting, S.,

Anand, P., & Mustacchia, P. (2023). The path to sustainable healthcare: Implementing

8

care transition teams to mitigate hospital readmissions and improve patient outcomes.

Cureus, 15(5). https://doi.org/10.7759/cureus.39022

1

Effectiveness of Transitional care in Reducing Hospital Readmissions within 30 days

Among Patients with Chronic Heart Failure

Antonio Estremera

FNU

Nursing Research and Evidence-Based Practice

Professor: Dr. Carmen Lazo

November 9, 2024

2

Effectiveness of Transitional care in Reducing Hospital Readmissions within 30 days

Among Patients with Chronic Heart Failure

Chronic diseases are among the leading causes of hospitalization, death, and economic

burden globally. Chronic diseases cause 73% of all deaths and 60% of the global disease burden,

respectively. One of the major problems in chronic disease management is the frequent

readmission of patients to hospitals; this is partly because transitional care is very fragmented.

More than 50% of patients with chronic diseases are readmitted to hospitals within 30 days

following discharge (Joo & Liu, 2021). Heart failure is among the major chronic diseases. It is a

prevalent condition affecting more than 6.7 million people aged 20 years and above in the United

States (CDC, 2024). Transitional care of patients with chronic conditions such as CHF is an

important element in health care, as it appraises continuity and safety as the patients undergo

different transitions from one care setting to another. Given the above figures, transitional care

interventions are crucial in reducing readmission rates to improve patient outcomes and decrease

overall healthcare system burdens. This paper discusses transitional care's role in managing CHF

patients post-discharge to minimize early hospital readmissions, drawing on prior nursing

research to emphasize its importance.

Identification of the Problem

Hospital readmission in the first 30 days after being discharged is a recurring problem in

healthcare, especially with patients diagnosed with chronic heart failure. These readmissions

may indicate potential gaps in discharge planning, patient education, and support in the post-

discharge periods, which are integral to transitional care (Ayenew et al., 2023). The majority of

patients with CHF are not engaged in illness self-management because of complex medical

regimens, diet restrictions or continuous monitoring. According to Becker et al. (2021), these

3

readmissions for admission happen due to failure in communication, follow-up services, and

support of such patients any time they go to their homes from the hospital. This issue is linked to

patient morbidity and mortality and healthcare system expenditures. Managing these factors may

improve post-discharge transitional care measures to improve patient stability and reduce

readmission rates in these populations (Rammohan et al., 2023).

Significance of the Problem to Nursing

This issue of readmission among CHF patients is highly significant in the nursing field,

especially in transitional and community-based settings. Nurses are central in discharge

planning, patient education, and coordinating care to support the patient through the transitional

period. Continuation of care is one of the major responsibilities of nursing professionals,

something quite relevant to these patients, who require detailed guidance in managing their

condition successfully at home (Karam et al., 2021). Nurses can help promote improved

compliance with treatment regimens, reduced medication errors, and increased patient-family

empowerment to engage in self-care through implementing and refining transitional care

strategies. The roles promote patient outcomes and support healthcare goals of quality of life and

preventable hospital readmissions. Transitional care, therefore, allows nurses to apply advanced

skills in the coordination of care, patient advocacy, and working collaboratively with other

professionals from other disciplines.

Purpose of the Research

This study aims to identify gaps in the current transitional care interventions and compare

the 30-day readmission rate for patients with chronic heart failure. This research will further

refine the understanding of which aspects of transitional care, including follow-up visits, patient

education, and home health monitoring, are the most valuable for avoiding early readmissions.

4

The research also aims to investigate how tailored transitional care plans can be adapted to meet

patients' individual needs, recognizing that CHF patients vary in severity, comorbid conditions,

and social support. The ultimate goal of this study is to provide evidence-based

recommendations for healthcare providers, particularly nurses, on best practices for managing

CHF patients post-discharge to improve outcomes and reduce readmissions.

Research Questions

1. What specific components of transitional care are most effective in reducing 30-day

readmission rates for patients with chronic heart failure?

2. How does patient education and self-management support during the transition period

impact readmission rates in this population?

3. How can individualized care plans enhance the effectiveness of transitional care for

patients with CHF?

4. What role do follow-up interventions, such as home visits or telehealth, play in

supporting CHF patients post-discharge?

Master's Essentials Aligned with the Topic

Essential I: Background for Practice from Sciences and Humanities

This essential underscores the need for nursing practice based on a wide knowledge of

sciences and humanities. During the care of patients with CHF, nurses will draw knowledge from

physiology, pharmacology, and patient psychology to develop comprehensive transitional care

plans addressing both physical and mental health. By integrating these multifaceted arenas of

cognition, nurses will be better equipped to develop holistic and personalized plans of care that

meet the complex needs of CHF patients during their transition from hospital to home.

Essential II: Organizational and Systems Leadership

5

This essential highlights the need for a higher level of professional nursing leadership

competencies to maneuver and coordinate healthcare systems environment solutions efficiently.

In particular, when discharging CHF patients, nurses need to involve other departments, support

the need for resources, and invest in structured transition plans to provide the appropriate care

continuity. Strong organizational and systems leadership allows nurses to reduce readmissions

through systemic improvements, demonstrating its impact on patient outcomes.

Essential III: Quality Improvement and Safety

This essential emphasizes utilizing improvement and quality management concepts to

boost the efficiency of patient safety as well as treatment. Nurses who work with CHF patients

diagnose the factors that cause readmission and implement knowledge-based changes in the

transitional care processes of the patients. Nurses play an important role in making discharge

plans safer and less risky, meaning they try to reduce the factors that can lead to readmission of

heart failure patients by paying a lot of attention to the safety of patients any time they are being

discharged or followed up.

Essential IV: Translating and Integrating Scholarship into Practice

This essential emphasizes the need for applied research conducted to enhance patient care

through the new implementation of practical nursing practices (Giddens et al., 2022).

Transitional care and readmission control are evidence-based practices. Hospital nurses use

research to handle CHF patients and apply effective solutions. They ensure the research findings

are implemented within practice, promoting patient care, especially for the most vulnerable.

Essential VII: Interprofessional Collaboration for Improving Patient and Population

Health Outcomes

6

This essential stresses the need to collaborate with an interactive and multifaceted team in

planning and providing client care that enhances pen-patient status. Transitional care for CHF

patients generally requires teamwork between nurses, physicians, pharmacists, social workers,

and home health aides to provide all health needs. This collaboration guarantees that CHF

patients get holistic and comprehensive care at each stage of their cycle, hence minimizing NICU

readmission rates.

Essential VIII: Clinical Prevention and Population Health for Improving Health

This essential calls for integrating preventive care and population health, increasing well-

being, and decreasing the number of disease incidents (Giddens et al., 2022). Transitional care

for CHF patients relates to and supports this goal by addressing the condition and averting

readmission by following up and educating patients on the necessary care. Nurses can use the

interventions to enhance the well-being of CHF patients and contribute to healthcare policies that

reduce the demands on health facilities.

7

References

Ayenew, B., Kumar, P., Hussein, A. A., Gashaw, Y., Girma, M., Ayalew, A., & Tadesse, B.

(2023). Heart failure drug classes and 30-day unplanned hospital readmission among

patients with heart failure in Ethiopia. Journal of Pharmaceutical Health Care and

Sciences, 9(1). https://doi.org/10.1186/s40780-023-00320-y

Becker, C., Zumbrunn, S., Beck, K., Vincent, A., Loretz, N., Müller, J., Amacher, S. A.,

Schaefert, R., & Hunziker, S. (2021). Interventions to Improve Communication at

Hospital Discharge and Rates of Readmission. JAMA Network Open, 4(8).

https://doi.org/10.1001/jamanetworkopen.2021.19346

CDC. (2024). Cardiovascular diseases (CVDs). Who. int. https://www.who.int/news-room/fact-

sheets/detail/cardiovascular-diseases

Giddens, J., Douglas, J. P., & Conroy, S. (2022). The Revised AACN Essentials: implications for

nursing regulation. Journal of Nursing Regulation, 12(4), 16–22.

https://doi.org/10.1016/s2155-8256(22)00009-6

Joo , J. Y., & Liu , M. F. (2021). Effectiveness of transitional care interventions for chronic

illnesses: A systematic review of reviews. Applied Nursing Research, 61, 151485.

https://doi.org/10.1016/j.apnr.2021.151485

Karam, M., Chouinard, M.-C., Poitras, M.-E., Couturier, Y., Vedel, I., Grgurevic, N., & Hudon,

C. (2021). Nursing care coordination for patients with complex needs in primary

healthcare: a scoping review. International Journal of Integrated Care, 21(1), 16.

https://doi.org/10.5334/ijic.5518

Rammohan, R., Joy, M., Magam, S. G., Natt, D., Patel, A., Akande, O., Yost, R. M., Bunting, S.,

Anand, P., & Mustacchia, P. (2023). The path to sustainable healthcare: Implementing

8

care transition teams to mitigate hospital readmissions and improve patient outcomes.

Cureus, 15(5). https://doi.org/10.7759/cureus.39022